Advances in Microbiology, 2013, 3, 515-519

Published Online November 2013 (http://www.scirp.org/journal/aim)

http://dx.doi.org/10.4236/aim.2013.37069

Microbiological Contamination of Bed Linen and Staff

Uniforms in a Hospital
Anthony Pinon, Jessica Gachet, Virginie Alexandre, Sandra Decherf, Michèle Vialette
Unité de Sécurité Microbiologique, Institut Pasteur de Lille, Lille, France
Email: anthony.pinon@pasteur-lille.fr

Received September 4, 2013; revised October 20, 2013; accepted November 7, 2013

Copyright © 2013 Anthony Pinon et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT
Hospital linen is clearly recognized as a potential reservoir for microorganisms and could be a vector of disease trans-
mission. The aim of this study was to isolate, count and identify fungi and bacteria from different kinds of clean and
dirty linen in a hospital. Microbiological samples have been collected on clean bed linen (n = 200), dirty bed linen (n =
192) and staff uniforms (n = 192) by using contact plates. 55% of samples from clean bed linen were contaminated be-
fore contact with the patient, with a mean count of 3 cfu/25 cm2 (range: 1 - 117 cfu) when contaminated. Virtually all
samples from dirty bed linen carried microorganisms, with a mean count of 23 cfu/25 cm2 (range 1 - 191 cfu). In addi-
tion, staff hospital uniforms showed the highest contamination rates in the study, with an average of 45 cfu/25 cm2
(range: 1 - 218 cfu). Microbial species were mostly bacteria commonly found in the environment or on human skin,
such as staphylococci or micrococci. Nevertheless, 57% of the identified species may be opportunistic pathogens for hu-
mans, representing a risk for people with a deficient or weakened immune system, especially in cases of superinfection.
Since contamination of linen seems to occur after washing, actively antimicrobial textiles would represent a valuable
measure to prevent textiles from being a vehicle for transfer of microorganisms.

Keywords: Linen; Bed Sheets; White Coat; Contamination; Hospital Acquired Infections

1. Introduction A study on white coats [8] reported 95% contamination,

Healthcare-associated infections (HAIs) represent a hea-
vy social and financial burden. In the USA, it was esti-
mated that 1.7 million cases of HAIs occurred yearly, with
almost 99,000 deaths related to these cases [1]. European
figures give an average prevalence of 7.1%, correspond-
ing to 4.5 million nosocomial infections each year [2].
Direct contamination is not the sole way of acquiring
HAIs; contamination through environment of the patient
has been identified as a possible route. Indeed, items in
contact with the patient or in its vicinity may be frequent-
ly contaminated. In two separate studies, 86% and 87%
of stethoscopes were found to be contaminated with bac-
teria, including staphylococci [3,4]; potentially pathoge-
nic bacteria were found on 81% of medical charts [5].
Textiles may act as reservoirs of microorganisms, since
pathogens may be able to survive on such surfaces for
periods ranging from a few minutes to several months [6,
7].
Various species of microorganisms, including some re-
levant for HAIs, have been isolated from hospital textiles.
while others found presence of Staphylococcus aureus in
23% of the white coats [9]; these bacteria appear to be
found more specifically around sleeves and pockets [10].
Pathogens were also found on other medical staff uni-
forms [11], or on bed linen in patients’ rooms [12]. Tex-
tiles may thus be responsible for transmission of patho-
genic microorganisms to patients, as a few studies de-
scribed transmission of microorganisms from uniforms to
patient and bed linen [13], or from dirty bed linen to staff
uniforms [14].
The aim of the present study was to evaluate the level
of microbial contamination on hospital textiles, based on
samples from clean and dirty bed linen, and from staff
uniforms. The analysis was both quantitative and qualita-
tive, including identification of microbial species.
2. Materials and Methods
2.1. Interviews
Methods for handling clean and dirty linen in the hospital
have been recorded. The industrial launderer responsible

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516 A. PINON ET
for washing textiles was also interviewed.
2.2. Sampling
Two sampling campaigns were carried out in a French
hospital on November and December 2011. Samples were
collected exclusively by trained staff from the microbi-
ology laboratory. Textiles were sampled according to the
following plan:
 20 non-occupied rooms were selected in various hos-
pital departments. In each room, 10 samples were col-
lected from the bed, which had recently been made by
the staff: fitted sheet (two sampling points at the cen-
tre), draw sheet (two sampling points at the centre),
upper sheet (inside and outside, at the centre), duvet
(near the head), pillow (at the centre), pillowcase (cen-
tre and opening). 200 samples (referred to as “clean
bed linen”) were thus obtained.
 Bed sheets that had been removed after use were sam-
pled in laundry rooms, which are actually storage
rooms for dirty linen before packing and sending to
the launderer. According to available pieces, fitted
sheets, draw sheets, or upper sheets were sampled
(respectively 25, 51, and 20 sheets), with two sample
points at the centre per item, amounting to 192 sam-
ples (referred to as “dirty bed linen”).
 Staff uniforms were sampled either in the room where
dirty uniforms are returned before laundering, or di-
rectly on the person (for the second sampling cam-
paign only). For each uniform, two sampling points
were selected, one on the chest and one on the pocket
(right by default, possibly left if the holder was pre-
sent and indicated left-handedness). Job title and de-
partment of the staff member having worn the uni-
form were recorded. 96 uniforms were sampled, with
two sampling points for each piece, making a total of
192 samples, regardless of the uniform’s nature (white
coat, scrub, or other).
Bed sheets were 50% polyester/50% cotton, while uni-
forms were 65% polyester/35% cotton.
2.3. Microbiological Analysis
The samples were taken by placing agar contact Hygi-
count 4N (AES Chemunex, Bruz, France) on each sam-
pling point (during 15 seconds). The surface of the plates
is 25 cm2. Plates were transported in ice to the laboratory.
After incubation at 32.5 +/−2.5˚C for 48 to 72 h, colonies
were differentiated according to their macroscopic ap-
pearance: colour, opacity, bulging, gloss, and contour. The
number of colonies of each type was counted. A copy of
each colony type was then isolated on PCA (Plate Count
Agar, AES Chemunex) for bacteria, or OGA (Oxytetra-
cycline Glucose Agar, Biokar Diagnostics, Beauvais,
France) for moulds. Bacteria isolated on PCA were iden-
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tified to the species level by API strips (bioMérieux, Cra-
ponne, France). Moulds were analyzed by scotch-test to
determine their genus.
2.4. Statistical Analysis
Statistical computations and tests were done using R sta-
tistical software [15]. Statistical differences evaluated by
Wilcoxon’s test were considered as significant when P-
value < 0.05.
3. Results
3.1. Laundry
In the hospital, dirty bed sheets are collected by the staff
in dedicated bags. These bags are stored in each aisle
(corresponding to one half of a floor) before being gath-
ered in a basement room where the launderer picks them
up for washing.
Uniforms are labeled with an electronic chip: each
staff member may collect up to 3 clean, personal uni-
forms per week. An automatic dispenser stores clean uni-
forms until claimed by the staff members. Dirty uniforms
are returned when the person decides to, in a unique re-
turn point. They are then collected by the launderer for
washing.
Washing is performed in industrial tunnel washers.
Procedures include application of chemicals (bleach, an-
timicrobial products) and high temperatures (up to 80˚C
for washing, smoothing out by vapor). Clean items are
packed in plastic bags. Periodic microbiological sampl-
ing of textiles leaving the laundry is performed.
In the hospital, clean bed sheets are stored in their
plastic bags in a dedicated, clean room in each aisle.
Beds are made by the hospital staff.
3.2. Clean Bed Linen
A summary of quantitative results on clean bed linen is
presented in Table 1. Pillows, pillowcases, and duvets
were the most frequently contaminated items. It was not
possible to determine whether the department (floor/ai-
sle) of the room had an influence on microbiological con-
tamination, because of the incomplete and unbalanced re-
partition of sampled rooms.
According to species identified from samples, a sum-
mary showing most represented microbial genera is pre-
sented in Table 2. Almost one half of the samples con-
tained Gram-positive cocci. Although most species corre-
spond to common environmental or skin microflora, 53%
of bacterial isolates (present in 38% of textile samples)
may be opportunistic pathogens for immunocompromis-
ed patients. Examples of such identified species include
various Staphylococcus species (91 isolates in 67 samples,
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 A. PINON ET AL. 517

Table 1. Contamination levels on clean bed linen, sorted by available, the time elapsed before the uniform was re-
decreasing order of contamination frequency; Q1, Q3: low- turned to the laundry (not necessarily connected to the
er and upper quartiles.
time it was worn, since staff members may keep clean
Plate count, cfu/25 cm2b uniforms in their lockers) was recorded; no correlation
Sampling Contamination
point frequencya
Signif.c between this time and the level of contamination was
Mean Median [Q1, Q3] Max found (data not shown).
Pillow 18/20 5 6 [3, 9] 30 AB Microbial genera identified on these textiles are pre-
Pillowcase
sented on Table 4, as a summary from identified species.
16/20 3 3 [2, 6] 14 ACD Staphylococci and micrococci were again the most wide-
opening
Pillowcase ly found genera. Opportunistic pathogens represented
15/20 6 6 [4, 12] 54 B approximately 58% of bacterial isolates (found in 95% of
centre
Duvet 15/20 5 4 [2, 10] 117 BC the textile samples), with various Staphylococcus species
(557 isolates in 356 samples, including six samples with
Inside upper
11/20 3 2 [1, 6] 24 BDE
sheet
Table 3. Contamination levels on bed linen and uniforms
Fitted sheet 19/40 2 1 [1, 3] 12 E after use, sorted by decreasing order of contamination fre-
Outside quency; Q1, Q3: lower and upper quartiles.
6/20 2 2 [1, 3] 3 CE
upper sheet
Plate count, cfu/25 cm2b
Contamination
Draw sheet 9/40 1 1 [1, 2] 3 E Sampling point Signif.c
frequencya
Mean Median [Q1, Q3] Max
All 109/200 3 3 [1, 7] 117
a
Uniform pocket 96/96 49 55 [32, 87] 218 A
number of samples with at least one cfu/total number of samples; bfor sam-
ples with non-empty plates; crows that do not share an uppercase letter are Uniform chest 96/96 42 39 [27, 82] 153 A
statistically different (P-value < 0.05).
Upper sheet 40/40 24 23 [11, 61] 191 B
Table 2. Microbial genera found on clean bed linen.
Draw sheet 102/102 23 35 [10, 69] 152 B
Genus Number (%) of samples Fitted sheet 49/50 22 22 [13, 31] 132 B
Staphylococcus 69 (35%) All 383/384 32 37 [18, 73] 218
Micrococcus 62 (31%) a
number of samples with at least one cfu/total number of samples; bfor sam-
ples with non-empty plates; crows that do not share an uppercase letter are
Bacillus 14 (7%) statistically different (P-value < 0.05).
Pseudomonas 13 (7%)
Table 4. Microbial genera found on bed linen and uniforms
Aspergillus 13 (7%) after use.
Other Gram-negative bacilli 22 (11%) Genus Number (%) of samples
Other Gram-positive bacilli 2 (1%)
Staphylococcus 357 (93%)
Other Gram-positive cocci 4 (2%)
Micrococcus 340 (89%)
Other moulds 11 (6%)
Pseudomonas 90 (23%)
Not identified 15 (8%)
Bacillus 66 (17%)

with two samples containing S. aureus), various Pseudo- Kocuria 22 (6%)

monas species (14 isolates in 13 samples), Bacillus cer- Pasteurella 20 (5%)
eus (two samples), Stenotrophomonas maltophilia (one
sample), or Gardnerella vaginalis (one sample). Ralstonia 20 (5%)

Other gram-negative bacilli 68 (18%)

3.3. Bed Sheets and Uniforms after Use
Other gram-positive bacilli 35 (9%)
Contamination of dirty bed linen and uniforms was sig-
Other gram-negative cocci 11 (3%)
nificantly higher than that of clean bed linen (P-value <
0.05). Results on these items are summarized in Table 3. Other gram-positive cocci 11 (3%)
On average, contamination of uniforms was twice as high Moulds or yeasts 8 (2%)
as contamination of dirty bed linen, although the latter
were sometimes visibly soiled by organic fluids. When Not identified 25 (7%)

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518 A. PINON ET
S. aureus), Pseudomonas species (99 isolates in 90 sam-
ples), Bacillus species (34 isolates in 33 samples), Burk-
holderia cepacia (eight samples), Stenotrophomonas mal-
tophilia (two samples), Aerococcus urinae (two samples),
or Gardnerella vaginalis (one sample).
4. Discussion
The contamination level of dirty bed linen and uniforms
evidenced in the present study is not uncommon. In a
study, the authors found a microbial load on white coats
after use at an average level of 24 cfu/25 cm2 [16], which
is similar to the average level of 45 cfu/25 cm2 on uni-
forms in the present study. Other researchers sampled pa-
jamas and bed sheets after one-night use, and found con-
tamination levels ranging from 102 to more than 105 cfu/10
cm2, which were larger than the average value of 23
cfu/25 cm2 on dirty bed linen in the present study, but it
was using a different sampling method, namely swabbing
[17]. While bed linen contamination obviously originates
mostly from the patient, uniforms were most likely con-
taminated both by skin microflora of the wearer and by
contact with contaminated surfaces during the work shift.
Contamination of clean bed linen may appear more
unexpected. In a number of studies, bed sheets sampled
before use did not appear to carry microbial loads [17,18].
Another one found that counts on clean white coats were,
on average, lower than 2 cfu/25 cm2 [16]. Washing pro-
cedures seem efficient for a removal of microorganisms
[19]. However, contamination may occur after washing,
but before contact with the patient: 14% of clean clothes
in staff dressing rooms were found to be contaminated by
S. aureus, and 10% by Clostridium sp. [20]. In the pre-
sent study, since textiles leaving the laundry appear to be
free from contamination (according to the launderer), al-
though they are not claimed to be sterile, most bacteria
found on “clean” bed linen likely originated from contact
between clean bed sheets and uniforms, while the bed
was made by the hospital staff. Since all samples from
uniforms were positive for presence of microorganisms,
regardless of the job of the wearer, these uniforms repre-
sent the most likely source of contamination of bed linen.
This is in agreement with studies showing a transfer of
microor- ganisms between various textiles [14]. It should
be noted that the relatively highly contaminated pillows
and du- vets are not changed as frequently as other items.
Most species identified from the samples correspond
to usual members of skin microflora or to bacteria from
the environment. Gram-positive cocci were the most pre-
valent species. These findings are coherent with other re-
ports [8,21,22]. A number of studies specifically focused
on searching HAI-relevant pathogens [2], mostly S. au-
reus or enterococci [9,11,23]. In the present study, only
eight samples contained S. aureus (two clean bed items,
three dirty bed sheets, three uniforms), and a single dirty
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bed sheet was contaminated with a non-pathogenic Ente-
rococcus strain. However, a majority of isolated species
may act as opportunistic pathogens, given the fragility
and possibly weakened immune system of patients stay-
ing in a hospital. Bacterial isolates were not tested for an-
timicrobial susceptibility, since our final objective is to
reduce the microbial load overall.
Contamination of staff uniforms may be considered as
the most relevant hazard identified from this study. In-
deed, although rules on hand hygiene have received wide
attention and nowadays are largely complied with, bene-
fits from clean hands may be partially lost by the fact that
contaminated uniforms are worn from one room to an-
other. The ubiquity of staff in a hospital thus represents a
likely route of infection spread possibly involving tex-
tiles. Therefore, the use of treated textiles having an an-
timicrobial activity may be beneficial for limiting HAIs
[24,25]. As a follow-up to the present results, similar
tests will be performed by using bed sheets and uniforms
with an antimicrobial activity.
5. Acknowledgements
This work was supported by Région Nord-Pas-de-Calais
and European regional development fund in the frame-
work of CROSSTEXNET ERA-NET Project Transnatio-
nal Call 2010 (Antibacterial flexible barrier to fight noso-
comial diseases in hospital and for medical applications-
BACNOS) from the European commission. Partners of
the project BACNOS are gratefully acknowledged: De-
van Chemicals NV, Colortex bvba, Centexbel, and Sub-
renat.
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